Screening, Brief Intervention and Referral to Treatment (SBIRT)

1. Screening, Brief Intervention and Referral to Treatment (SBIRT) A training for personnel from trauma centers, emergency departments and primary care settings

2. What is SBIRT? SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services • For persons with substance use disorders • Those who are at risk of developing these disorders Primary care centers, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users Before more severe consequences occur

3. SBIRT: Core Clinical Components • Screening: Very brief screening that identifies substance related problems • Brief Intervention: Raises awareness of risks and motivates client toward acknowledgement of problem • Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help • Referral: Referral of those with more serious addictions

4. 19.7 Any Illicit Drug 14.6 Marijuana 9.0 Any Illicit Drug, not marijuana 6.4 Psychotherapeutics (non-medical use) 2.4 Cocaine 0.7 Crack 0.5 Ecstasy 0.5 Meth 0.6 Inhalants 0.1 Heroin 0.1 LSD 0 5 10 15 20 Substance Abuse Challenges: 19.7 Million Americans Are Current* Users of Illicit Drugs (in millions) *past month users Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006).

5. Non-Medical Use of Psychotherapeutics Substance Abuse Challenge:

6. Substance Abuse Challenge:Prescription Drug Sources: Primarily Friends or Family Sources of OpioidPain Relievers Used Non-Medically 28% Source: SAMHSA, 2005 National Survey on Drug Use and Health, September 2006

7. Public Health Challenge Conclusion: The vast majority of people with a diagnosable illicit drug or alcohol disorder are unaware of the problem or do not feel they need help. Source: SAMHSA, 2005 National Survey on Drug Use and Health (September 2006).

8. Just a few slides on screening…

9. Screening in action Screening Assessment

10. Screening Conducted with large numbersof people to identify the potentialthat a problem exists Screening is intended to be broad scale and produce false positives Screening leads to more in-depth assessment and intervention for people identified with a potential problem

11. Benefits of screening • Provides opportunity for education, early intervention • Alerts provider to risks for interactions with medications or other aspects of treatment • Offers opportunity to engage patient further • Has proved beneficial in reducing high-risk activities for people who are not dependent (Source: NCETA, 2004)

12. SBI Procedures:Follow-up Action Depends on Score Screening Score Negative Screen Positive screen Positive Reinforcement Moderate Use Moderate/High Use Abuse/Dependence Brief Intervention Brief Treatment Referral to Treatment

13. Screening, Brief Interventions for Alcohol: Major Impact of SBI on Morbidity and Mortality

14. Screening, Brief Interventions for Alcohol:Saves Healthcare Costs

15. Screening to Identify Patients At Risk for Alcohol and Drug Problems

16. Alcohol Problems Among Trauma Patients SBIRT SBIRT

17. Characteristics of a good screening tool • Brief (10 or fewer questions) • Flexible • Easy to administer, easy for patient • Addresses alcohol & other drugs • Indicates need for further assessment or intervention • Has good sensitivity and specificity

18. Menu of Screening Tools • BAC/Drug Screen (biological measures) • CAGE(4 questions—alcohol only) • DAST (10 questions—drugs only) • AUDIT(10 questions—alcohol only) • AUDIT-C+ (5 questions—both alcohol and drugs—not well studied) • ASSIST (8 questions for each substance used— alcohol, drugs and tobacco—LONG)

19. MI - The Spirit (1) : Style • Nonjudgmental and collaborative • based on client and clinician partnership • gently persuasive • more supportive than argumentative • listens rather than tells • communicates respect for and acceptance for clients and their feelings

20. Conducting the Brief Intervention FLO

21. The 3 Tasks of a BI F L O W Avoid Warnings! Warn Feedback Options Explored Listen & Understand (that’s it)

22. How does it all fit together?

23. How you talk to the patient matters You’re not doing it right if you if you find yourself… • Challenging • Warning • Finger-wagging • Moralizing • Giving unwanted advice • Shaming • Labeling • Confronting • Being Sarcastic • Playing expert

24. The 3 Tasks of a BI F L O Feedback Options Explored Listen & Understand

25. The First Task: Feedback Give Patient Feedback using: • R • A • N • G • E • Range • Anybody knows • Normal ranges • Give score • Elicit reaction

26. The First Task: Feedback Give Patient Feedback: An Example • Range: “BAC can range from 0 (sober) to .4 (lethal)” • Anybody knows: “.08 defines drunk driving (heavy drinking)” • Normal: “Normal drinking is .03-.05 • Give score: “Your level was …” • Elicit reaction: “What do you make of that?”

27. The First Task: Feedback • •Your job in F is only to deliver the feedback! • •Let the patient decide where to go with it.

28. The First Task: Feedback To avoid this… LET GO!!!

29. The First Task: Feedback Easy Ways to Let Go… • I’m not going to push you to change anything you don’t want to change • I’m not hear to convince you that you’re an alcoholic. • I’d just like to give you some information.. • I’d really like to hear your thoughts about… • What you do is up to you.

30. The First Task: Feedback Finding a Hook • Ask the client about their concerns • Provide non-judgmental feedback/information • Watch for signs of discomfort with status quo or interest or ability to change • You cannot know the truth; you were not there. • Let the patient decide. • Just asking the question is helpful. • Always ask this question: “What role, if any, do you think alcohol played in your getting injured?

31. The 3 Tasks of a BI F L O Feedback Options Explored Listen & Understand

32. The Second Task: Listen and Understand Ambivalence is Normal

33. The Second Task: Listen and Understand • Change Talk • DESIRE: I want to do it. • ABILITY: I can do it. • REASON: I can’t afford to lose my job. • NEED: I have to do it. • COMMITMENT!!! I WILL DO IT.

34. The Second Task: Listen and Understand Listen for the change talk… Maybe drinking did play a role in what happened If I wasn’t drinking this would never have happened It’s not really much fun anymore I can’t afford to be in this mess again The last thing I want to do is hurt someone else I know I can quit because I’ve stopped before Summarize, so they hear it twice!

35. The Second Task: Listen and Understand • Dig for change talk… • I’d like to hear your opinions about… • What are some things that bother you about drinking? • What role do you think alcohol played in your injury? • How would you like your drinking to be 5 years from now?

36. The Second Task: Listen and Understand • Tools for Change Talk • Pros and Cons • Importance & Confidence Scales • Readiness Ruler

37. The Second Task: Listen and Understand • Strategies for weighing the pros and cons… • “What do you like about drinking?” • “What do you see as the downside of drinking?” • “What Else?” • Summarize both pros and cons… • “On the one hand you said.., • and on the other you said….

38. The Second Task: Listen and Understand • Importance/Confidence/Readiness • On a scale of 1–10… • How important is it for you to change your drinking? • How confident are you that you can change your drinking? • How ready are you to change your drinking? • For each ask… • Why didn’t you give it a lower number? • What would it take to raise that number? 1 2 3 4 5 6 7 8 9 10

39. The Second Task: Listen and Understand Let’s practice L: Role Playing Listening and Understanding • Pros and Cons • Importance/Confidence/Readiness Scales • Summary

40. The Second Task: Listen and Understand Let’s practice L: Role Playing Listen and understand (Interviewer) • Begin with a structuring statement that ends with an open question • There is no need to fix or change the interviewee’s opinion • Listen empathically: use reflections and open ended questions as much as possible • After 10 minutes or so bring the interview to a close by offering a summary

41. The Second Task: Listen and Understand Let’s practice L: Role Playing Listen and Understand (Patient) • Pick something that you feel two ways about but would like to change • Pick something that you are comfortable sharing but has some meaning for you • Say as much or as little as seems natural to you • Expect to converse for about ten minutes

42. The 3 Tasks of a BI F L O Feedback Options Explored Listen & Understand

43. The Third Task: Options for Change What now? What do you think you will do? What changes are you thinking about making? What do you see as your options? Where do we go from here? What happens next?

44. The Third Task: Options for Change Offer a Menu of Options Manage your drinking (cut down to low-risk limits) Eliminate your drinking (quit) Never drink and drive (reduce harm) Utterly nothing (no change) Seek help (refer to treatment)

45. The Third Task: Options for Change • During MENUS You can also explore previous strengths, resources and successes • “Have you stopped drinking/using drugs before?” • “What personal strengths allowed you to do it?” • “Who helped you and what did you do?” • “Have you made other kinds of changes successfully in the past?” • “How did you accomplish these things?”

46. The Third Task: Options for Change The Advice Sandwich Ask permission Give Advice Ask for Response

47. The Third Task: Options for Change When to Give Advice • Does the client already know what I have to say? • Have I elicited the client’s knowledge regarding this information? • Is what I’m about to say going to be helpful to the client (i.e., reduce resistance and/or increase change talk)

48. The Third Task: Options for Change Giving Advice Without Telling Someone What to Do • Ask for Permission explicitly • There’s something that concerns me. • Would it be ok if I shared my concerns with you? • Preface advice with permission to disagree • This may or may not be helpful to you

49. The Third Task: Options for Change Giving Advice Without Telling Someone What to Do • Provide Clear Information or Feedback • The results of your test suggest that… • What happens to some people is that… • My recommendation would be that… • Elicit their reaction • What do you think? • What are your thoughts?

50. The Third Task: Options for Change Closing the Conversation S E W • S • E • W • Summarize patients views (especially the pro) • Encourage them to share their views • What agreement was reached (repeat it)